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Dosing for erythropoiesis-stimulating agents (ESAs, including epoetin, epoetin biosimilars, and darbepoetin) in adults with non-hematologic cancer

Dosing for erythropoiesis-stimulating agents (ESAs, including epoetin, epoetin biosimilars, and darbepoetin) in adults with non-hematologic cancer
  3 times per week dosing Once per week dosing
Epoetin alfa (including biosimilars)
Starting dose (adults) 150 units/kg SUBQ 3 times per week 40,000 units SUBQ once per week*
Dose-reductions or interruptions

Reduce dose by 25% if the hemoglobin reaches a level needed to avoid RBC transfusion or increases >1 g/dL in any 2-week period.

Withhold the dose if the hemoglobin exceeds a level needed to avoid RBC transfusion, and restart at 25% below the previous dose when the hemoglobin approaches a level where RBC transfusions may be required.
Dose increases The dose can be increased after 4 weeks of therapy if the hemoglobin remains <10 g/dL and the rise in hemoglobin is <1 g/dL. Ensure iron stores are adequate.
Increase to 300 units/kg SUBQ 3 times per week Increase to 60,000 units SUBQ once per week
  Once per week dosing Once every 3 weeks dosing
Darbepoetin alfa
Starting dose (adults) 2.25 micrograms/kg SUBQ once per week 500 micrograms SUBQ once every 3 weeks
Dose-reductions or interruptions

Reduce dose by 40% if the hemoglobin reaches a level needed to avoid RBC transfusion or increases >1 g/dL in any 2-week period.

Withhold the dose if the hemoglobin exceeds a level needed to avoid RBC transfusion, and restart at 40% below the previous dose when the hemoglobin approaches a level where RBC transfusions may be required.
Dose increases

The dose can be increased after 6 weeks of therapy if the hemoglobin remains <10 g/dL and the rise in hemoglobin is <1 g/dL. Ensure iron stores are adequate.

Increase to 4.5 micrograms/kg SUBQ once per week.		 Dose increase not recommended

In individuals with non-hematologic cancer, an ESA may be considered for treatment of symptomatic anemia with hemoglobin <10 g/dL that is induced by chemotherapy.

  • Ensure adequate iron stores before starting an ESA and during ESA treatment.
  • ESA doses are often rounded to the nearest full vial size or syringe.
  • ESA therapy is discontinued after chemotherapy is completed and if there is inadequate response after 8 weeks of therapy, such as no increase in hemoglobin or no reduction in transfusion requirements.
  • Ensure that other causes of anemia have been addressed, including insufficient iron stores.

Refer to UpToDate for further information on the role of ESAs in non-hematologic cancers.

ESA: erythropoiesis-stimulating agent; RBC: red blood cell; SUBQ: subcutaneously.

* If initial therapy is tolerated and effective, extended dosing schedules may be used (eg, 80,000 units every 2 weeks or 120,000 units every 3 weeks).
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